David M. Shribman: Learning from Obamacare

The president got his legacy legislation, but there are better ways to get big things done

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An historic deadline beckons Monday. Most Americans without health insurance must have started to apply for coverage by that deadline or face a financial penalty. It’s the first time that health insurance has been extended to virtually all Americans, and it marks a landmark in American cultural and economic history.

The Monday deadline also has a more prosaic meaning. It brings to an end a frantic period during which the Obama administration struggled to perfect its insurance-application process and then struggled to persuade Americans to use it. Neither struggle has been pretty. Nor has the political cacophony that has accompanied it.

But this deadline also offers Americans a health-care breather. The next enrollment period doesn’t begin until November. It is a good time to take stock of what the health-care debate has meant and what lessons can be learned from it. Here are some of them:

• Vast social change is best accomplished in a bipartisan way.

From the start, this was the Obama administration’s principal error. It grew in part out of the Obama team’s determination to slam a health-care bill through Congress at the time of the new president’s greatest appeal and power, but it in fact diminished Mr. Obama’s appeal and power even as it undermined the moral authority of the legislation.

The blame isn’t Mr. Obama’s alone. The Republicans swiftly and shrewdly identified this as the signature Obama initiative and were determined to deny him his triumph. But the burden of leadership — the burden of persuasion — was on the shoulders of the president, who swept into office covered in the same sort of fairy dust that sat 28 years earlier on the shoulders of Ronald Reagan, whose proposals were as anathema to Democrats in 1981 as Mr. Obama’s were to Republicans in 2009. Mr. Reagan, in admittedly different times, drew some Democratic support for his tax and budget cuts. The failure of Mr. Obama to do the same with a handful of moderate Republicans remains a stain on this legislation.

• Politics is a matter of sales as much as substance.

Mr. Obama surely should have known this, he being one of the masters of this discipline. He, after all, was able to sell the American people on the notion that a little-known U.S. senator only four years out of the Illinois statehouse was a plausible candidate to break a 22-decade racial barrier to the presidency. In that context, selling a fundamental good to a country that prided itself on its sense of justice and fairness was easy in comparison.

He failed to do so. In fact, having won the ground war (the gritty effort to push the legislation through Congress) he lost the air war (on cable and on talk radio, and then in the mainstream press) on health care.

• Be honest about what you are selling.

Here is a fundamental Obama failure, in two dimensions. The first was the claim, perhaps disingenuous, perhaps sloppy, that Americans could keep the health-care plans they had under the new legislation. This was demonstrably false.

The second: One of the flaws of Obamacare is that it promised more than it delivered. “This plan was designed to make people feel good but not to solve the problem,” says David W. Scott, president of the Ohio Valley General Hospital in Kennedy. “We’re insuring the uninsured, but for all intents and purposes people don’t have the care they need because of the high deductibles, and they don’t have access to preventive care and their basic needs.”

• The sales pitch must include an honest reckoning of limitations and likely problems.

The Obama administration sold its health-care initiative as requiring little more effort than filling out an NCAA basketball tournament bracket and as providing comprehensive care for everyone. That just wasn’t so.

“Could it be more clear? Less complicated? Absolutely,” says Diane Holder, president of the UPMC Health Plan in Pittsburgh. “Is it directionally correct? Yes. Will it ultimately help a sufficient number of people? I think so.”

• Keep the process transparent.

Obamacare was created in an atmosphere far more open than the environment that produced the Hillary Clinton health-care plan, which is one reason the Obama proposal is law today and the Clinton plan is not.

But the Obama team allowed a dangerous narrative to be created, the notion that the system it was creating was needlessly complicated. The truth is that the system is complicated not because of a government takeover but because the administration left in place so many elements of the existing system.

“The irony of it all is that the reason it’s so complex is that the administration tried to preserve as much as possible from the current system,” says Stuart Altman, a Brandeis economist specializing in health policy. “The result was a system even more complex.”

• Sell to the middle, not to the extremes.

Of all the guidelines that emerge from this episode, this is the one the administration has mastered best. The liberals who demanded a single-payer system and the conservatives who were going to oppose on principle, or out of habit, anything the president proposed are stewing. But at the end of the day — or in this case, at the end of this month — the president has a health-care overhaul worthy of the name if not of everyone’s best hopes.

It would have been better had the software worked, it would have been better if the national consensus were broader, it would have been better had bureaucratic delay not been piled upon bureaucratic delay. But his critics on both sides of the argument are going to have to concede that history will attach health-care overhaul to Barack Obama’s name. That may be the biggest lesson of all.

David M. Shribman is executive editor of the Post-Gazette (dshribman@post-gazette.com, 412-263-1890).

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